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The Ohio Department of Aging

Ohio Department of Aging Long-term Care Non-Agency Provider (PASSPORT Waiver)

Long-term Care Non-Agency Provider 

Prior to apply for certification, please read and understand the conditions of participation and service requirements for which you are seeking certification.  View this information as well as all current effective rules.

Applicants applying to the Ohio Department of Aging to be certified as a non-agency provider for the PASSPORT Medicaid Waiver Program may request certification for the following services:

Alternative Meals
Non-Emergency Medical Transportation
Chore
Non-Medical Transportation
Community Transition
Nutrition Consultation
Home Medical Equipment/Supplies
Pest Control
Minor Home Modification
Social Work/Counseling

 

Documentation you will be required to submit:

  • Evidence of Services Provided:  Documentation you have provided services to two adults for a minimum of three months for all service you are requesting certification.  (Example:  requesting certification as a personal care provider, please provide time sheets or task sheets that clearly show the duties completed in the consumer's home.)
     
  • Evidence of Payment for Services:  Documentation you have received payment for services to two adults for a minimum of three months.  (Example: copy of invoice used to bill consumer for services and evidence you received payment for those services.)  Payment for these services can be from private pay, insurance, other Medicaid/Medicare programs, etc. 
  • Registration with the Ohio Secretary of State. A copy of registration certificate with the Ohio Secretary of State.
     
  • Ohio Bureau of Workers’ Compensation Certificate. A copy of current certificate in good standing with the Ohio Bureau of Workers’ Compensation.
     
  • Certificate of Commercial Liability Insurance. A copy of current policy of minimum of one million dollars in commercial liability insurance.
     
  • Employee Dishonesty or Property Damage Insurance. A copy of current insurance policy for employee dishonesty or property damage to others.  This requirement can be a warranty, surety or business services bond.
     
  • Table of Organization: A copy of a table of organization that includes the full name of each position and indicates lines of authority.
     
  • Completed and Signed W-9: This form will automatically be completed and available to download for signature during application process.
     
  • Ohio Health Plans Provider Enrollment Application/Time Limited Agreement for Organization: This form will automatically be completed and available to download for signature during application process.
     
  • Proof of Residency:  Evidence that applicant/CEO has been a resident of Ohio for the last five consecutive years.  Acceptable documentation includes: valid driver's license; notification of registration as an elector; a copy of an officially filed federal or state tax form identifying the applicant's permanent residence; any other documentation the responsible entity considers acceptable showing evidence the applicant has been a resident of Ohio for the past five years.  If you currently live or have lived outside of Ohio anytime in the past five years, you are required to submit an FBI background check.
     
  • FBI record check (if live or have lived outside of Ohio in past 5 years): If you have lived outside of Ohio anytime in the past five years, you are required to submit a FBI background check.
  • Non-Disclosure Statement:  This form will be available to download for signature during the online application process.  
     

Required documentation can be submitted by:

  • Upload directly to application prior to submission
     
  • Fax to 614-466-9812 or 614-466-5741
     
  • Mail to:
    Ohio Department of Aging
    Provider Certification
    50 West Broad Street, 9th Floor
    Columbus, OH 43215

 

PLEASE NOTE: documentation emailed to our office will not be accepted and can delay the processing of your application.

 

    I acknowledge I have read and understand the above information.

Apply now